The Gist

  • Circumcision has been found to reduce the risk of certain health conditions, such as urinary tract infections and some sexually transmitted diseases, but not enough for the American Academy of Pediatrics to recommend the procedure.
  • Infant circumcision is generally safe, with a complication rate of about 1.5 percent.
  • Overall, circumcision does not have a significant impact on the health of babies born in the United States, so religious, social and cultural factors play an important role in parents’ decisions.
  • Circumcisions should be done by a trained practitioner, ideally before 6 weeks of age. Protect and monitor the circumcision site until it has fully healed.
  • No special hygiene is required for an uncircumcised infant; as the boy grows, he will learn to gently retract the foreskin when peeing or bathing.

By Susan Reslewic Keatley

This guide was originally published on July 12, 2019 in NYT Parenting.

Should you circumcise your newborn son? For some parents, the answer is clear from the moment they know they’re having a boy. For others, the decision is more fraught, and may be anxiously debated clear on into the delivery room and beyond.

Male infant circumcision, or the removal of the foreskin from a baby boy’s penis, is far more common in the United States than it is in most industrialized countries, but rates have declined since the 1970s, according to the Centers for Disease Control and Prevention. A 2013 C.D.C. report that analyzed decades of hospital data found that the national rate of newborn circumcision dropped from about 65 percent to about 58 percent between 1979 and 2010.

Though the decision to circumcise is guided by religious tradition for some families, most of the American parents who choose circumcision do so for other reasons — because they believe a circumcised penis is easier to keep clean, for example, or because they want a boy’s penis to look like that of his father or peers. But while the American Academy of Pediatrics’ 2012 policy statement on circumcision argued that the medical benefits outweigh the risks, it stopped short of recommending the procedure. And, as circumcision rates decline, your son is likely to have friends who look like him no matter what you choose to do.

So how should parents decide?

“First, take a breath,” said Dr. Andrew Freedman, M.D., a pediatric urologist and member of the A.A.P. task force behind the 2012 policy. “Whatever you do, your child will be fine,” he continued, explaining that many factors — medical, religious, cultural and social — may be at stake when considering circumcision.

In addition to Dr. Freedman, I spoke with another pediatric urologist, a pediatrician, an obstetrician, and two professors of obstetrics and gynecology who have written about infant circumcision. The experts agreed that parents should weigh the medical benefits and risks of circumcision in the context of religious, social and cultural preferences. They also advised parents to learn how to care for their son’s penis, with or without a foreskin, and how to recognize complications.

Prevention of urinary tract infections is considered the most compelling medical benefit of infant circumcision in the United States, said Dr. Ellen Shapiro, M.D., director of pediatric urology and a professor of urology at NYU Langone Medical Center. The risk of urinary tract infections in uncircumcised boys under age 2 is about 1 percent; in circumcised boys, the risk decreases to about 0.1 percent.

Some observational studies have found that adult men who were circumcised as babies were less likely to get penile cancer. However, in studies that controlled for known risk factors like phimosis — a condition where the foreskin of an uncircumcised man is tight and difficult to retract — the protective effects of circumcision appeared to diminish. Penile cancer is so rare in the United States that an estimated 300,000 newborns would have to be circumcised in order to prevent a single case.

Circumcision has been shown reduce the risk of some sexually transmitted infections, including herpes, syphilis and H.I.V. However, the H.I.V. studies were done in Africa, where overall H.I.V. rates are much higher, and where, unlike in the United States, heterosexual sex is the main mode of transmission. (Studies investigating whether circumcision helps protect against H.I.V. in men who have sex with men have been inconclusive.) Researchers don’t yet fully understand the mechanism by which circumcision reduces H.I.V. transmission; some have suggested that tiny abrasions in the delicate foreskin, combined with a warm, moist environment, may leave uncircumcised men more vulnerable to infection. Circumcising to prevent H.I.V. in the United States doesn’t make sense from a cost and risk standpoint, said Dr. Timothy Johnson, M.D., a professor of obstetrics and gynecology at the University of Michigan Von Voigtlander Women’s Hospital. Dr. Laurie Schulwolf, M.D., a pediatrician at Tribeca Pediatrics in New York City, put it even more bluntly. “For H.I.V. and S.T.D.s,” Dr. Schulwolf said, “a condom goes so much further than a circumcision.”

Only about 1.5 percent of circumcised infants experience complications during the five years after the surgery. Bleeding and infection are the most common complications, and must be addressed by a doctor right away, Dr. Freedman said. Adhesions, which occur when skin from the shaft of the penis sticks to the tip, are also common; these often resolve on their own, but may require treatment with a steroid cream, such as betamethasone, Dr. Shapiro said. An untreated adhesion can go on to form a thickened band of skin called a skin bridge, which may need to be surgically removed. Another less common complication of circumcision, meatal stenosis, occurs when inflammation and scarring compress the urethra, making urination difficult.

Overall, circumcision is a safe, low-risk procedure for newborns, said Dr. George Mussalli, M.D., an obstetrician at Village Obstetrics in Manhattan and an associate professor of clinical obstetrics and gynecology and women’s health at Albert Einstein College of Medicine.

Globally, circumcision rates vary widely. Since both Jewish and Islamic religious traditions promote the procedure, circumcision rates are over 95 percent in parts of the Middle East. In Western Europe, where non-medical infant circumcision has become increasingly controversial, and children’s rights groups have proposed banning the circumcision of minors, rates are under 20 percent. “In much of the world, newborn circumcision is not primarily a medical decision,” wrote Dr. Freedman, in a 2016 paper on the circumcision debate. Even in the United States, he noted, where “parents may use the conflicting medical literature to buttress their own beliefs and desires,” most parents ultimately decide whether or not to circumcise for non-medical reasons. “There can be no doubt that religion, culture, aesthetic preference, familial identity and personal experience all factor into their decision,” Dr. Freedman wrote.

It may be helpful for parents to consider their cultural context, said Dr. Allan Jacobs, M.D., director of gynecological oncology at Coney Island Hospital and a professor of obstetrics, gynecology and reproductive medicine at Stony Brook University School of Medicine. “Someone might think, ‘If I’m living in Sweden, maybe I won’t circumcise, but if I’m living in Israel, I will.’”

“I try to get parents to say why they are doing it,” said Dr. Freedman, who advises parents to weigh the cultural, medical and other aspects of the decision and then to do what they believe is in the best interests of their child. “If it is important for you to do it for non-medical reasons, you should be allowed to do it,” Dr. Freedman continued. “You shouldn’t feel pressured either way.”

Before being circumcised, an infant must be cleared by a doctor; he should not be underweight, and should not have a bleeding disorder or other serious medical issues. To reduce complications, the circumcision should be done by a trained practitioner — typically an obstetrician, sometimes a pediatrician — who uses sterile techniques. The procedure is quick, lasting only 10 to 15 minutes, and parents may be present if they wish. In the past, babies were often circumcised without anesthesia, but most providers now use some form of pain relief. Your doctor may apply a topical anesthetic cream, or inject a local anesthetic, to numb the penis before the procedure. If you plan to circumcise your son, it is best to do it before 6 weeks of age; afterward, circumcision must be done with general anesthesia in an operating room. In addition, the risk of complications increases with the age of the baby.

Dr. Mussalli recommended frequently checking your son’s diaper for blood during the first few hours after the procedure, and contacting your provider if you notice more than a few drops. He also recommended an extra pair of hands for diaper changes, to hold the baby’s feet and prevent him from kicking the circumcision spot, which could cause bleeding. Parents should use a shot glass of water at a comfortable temperature to rinse pee or poop off the penis, instead of disturbing the area by wiping. But cleaning too gingerly can raise the risk of adhesions in the first few days, when the skin on the tip of the penis is sticky, Dr. Mussalli warned. Dr. Mussalli also recommended putting petroleum jelly on the inside of the diaper, to prevent the penis from sticking to the diaper as it heals. After about a week, you should be able to resume regular diaper care.

An uncircumcised infant’s foreskin is naturally tight, but will relax as the child grows. Many boys are able to retract their foreskins by age 5, and nearly all are able to do so by puberty. “Nobody should do any special cleaning for an infant,” said Dr. Schulwolf, who added that parents do not need to try to retract and clean under their child’s foreskin. “By kindergarten or first grade, boys can learn to retract their foreskin themselves, wash the area, and then put it back.” In fact, forcible retraction by a well-meaning parent or grandparent may hurt a child, said Dr. Shapiro.

In rare cases, a child’s foreskin may not relax on its own, a condition called phimosis. (Phimosis can also be caused by forcible retraction of the foreskin before it has sufficiently relaxed). Treatment with steroid cream may help loosen the foreskin, said Dr. Shapiro, and in some situations, a circumcision may be required. In a 2014 study from Denmark, where male infant circumcision is relatively rare, fewer than 2 percent of boys under 18 needed a later operation due to foreskin problems, primarily phimosis.

If you spot any signs of bleeding, infection or anything that doesn’t look right (including adhesions or skin bridges) after your son’s circumcision, report them to your doctor immediately. Phimosis may cause balanitis (inflammation of the penis head) or balanoposthitis (inflammation of the penis head and foreskin) and should be examined by a doctor. Paraphimosis occurs when the foreskin is retracted and gets stuck — this is a rare but serious situation as it can impair blood flow, and a doctor should be seen right away.

Susan Reslewic Keatley holds a Ph.D. in chemistry and blogs at I Love a Good Story. She is the mother of two children.